Lower mortality and earlier start of combination antiretroviral therapy in patients tested repeatedly for HIV than in those with a positive first test

Socioeconomic factors impact the risk of HIV acquisition in the township population of South Africa: A Bayesian analysis

With a prevalence almost twice as high as the national average, people living in South African townships are particularly impacted by the HIV epidemic. Yet, it remains unclear how socioeconomic factors impact the risk of HIV infection within township populations. Our objective was to estimate the extent to which socioeconomic factors (dwelling situation, education, employment status, and monthly income) explain the risk of HIV in South African township populations, after controlling for behavioural and individual risk factors. Using Bayesian logistic regression, we analysed secondary data from a quasi-randomised trial which recruited participants (N = 3095) from townships located across three subdistricts of Cape Town. We controlled for individual factors (age, sex, marital status, testing history, HIV exposure, comorbidities, and tuberculosis infection) and behavioural factors (unprotected sex, sex with multiple partners, with sex workers, with a partner living with HIV, under the influence of alcohol or drugs), and accounted for the uncertainty due to missing data through multiple imputation. We found that residing in informal dwellings and not having post-secondary education increased the odds of HIV (aOR, 89% CrI: 1.34, 1.07-1.68 and 1.82, 1.29-2.61, respectively), after controlling for subdistrict of residence, individual, and behavioural factors. Additionally, our results suggest different pathways for how socioeconomic status (SES) affect HIV infection in males and female participants: while socioeconomic factors associated with lower SES seem to be associated with a decreased likelihood of having recently sough HIV testing among male participants, they are associated with increased sexual risk taking which, among female participants, increase the risk of HIV. Our analyses demonstrate that social determinants of health are at the root of the HIV epidemic and affect the risk of HIV in multiple ways. These findings stress the need for the deployment of programs that specifically address social determinants of health.

Level of viral suppression and the cascade of HIV care in a South African semi-urban setting in 2012

OBJECTIVE

In 2012, 7 years after the introduction of antiretroviral treatment (ART) in the South African township of Orange Farm, we measured the proportion of HIV-positive people who were virally suppressed, especially among high-risk groups (women 18-29 years and men 25-34 years).

DESIGN

A community-based cross-sectional representative survey was conducted among 3293 men and 3473 women.

METHODS

Study procedures included a face-to-face interview and collection of blood samples that were tested for HIV, 11 antiretroviral drugs and HIV-viral load.

RESULTS

HIV prevalence was 17.0% [95% confidence interval: 15.7-18.3%] among men and 30.1% [28.5-31.6%] among women. Overall, 59.1% [57.4-60.8%] of men and 79.5% [78.2-80.9%] of women had previously been tested for HIV. When controlling for age, circumcised men were more likely to have been tested compared with uncircumcised men (66.1 vs 53.6%; P < 0.001). Among HIV+, 21.0% [17.7-24.6%] of men and 30.5% [27.7-33.3%] of women tested positive for one or more antiretroviral drugs. Using basic calculations, we estimated that, between 2005 and 2012, ART programs prevented between 46 and 63% of AIDS-related deaths in the community. Among antiretroviral-positive, 91.9% [88.7-94.3%] had viral suppression (viral load <400 copies/ml). The proportion of viral suppression among HIV+ was 27.0% [24.3-29.9%] among women and 17.5% [14.4-20.9%] among men. These proportions were lower among the high-risk groups: 15.6% [12.1-19.7%] among women and 8.4% [5.0-13.1%] among men.

CONCLUSION

In Orange Farm, between 2005 and 2012, ART programs were suboptimal and, among those living with HIV, the proportion with viral suppression was still low, especially among the young age groups. However, our study showed that, in reality, antiretroviral drugs are highly effective in viral suppression at an individual level.

Time since last negative HIV test among men who have sex with men and people who use injection drugs in British Columbia, 2006-2011

OBJECTIVES

Canadian surveys of men who have sex with men (MSM) and people using injection drugs (IDU) demonstrate that most have tested for HIV at least once, but that half or fewer have done so in the previous year. To better inform targeted HIV testing guidelines for these populations, we derived estimates of inter-test interval (ITI) for persons newly diagnosed with HIV in British Columbia (BC) between 2006 and 2011, and assessed variables associated with longer ITI among MSM and IDU.

METHODS

Provincial HIV case report and testing data were linked by deterministic and probabilistic matching (based on unique personal health number, name, and date of birth). ITI was defined as time from last recorded negative to first positive HIV result; those with ITI ≤30 days were excluded.

RESULTS

Of 2,004 eligible individuals, 1,116 (55.7%) had a recorded negative HIV test result in the previous ten years. Overall median ITI was 20 months with a skewed distribution (inter-quartile range 8-46); median ITI was 15 months for MSM and 21 months for IDU with 41.2% and 33.1% testing in the past year, respectively. Longer ITI was associated with older age for both groups, and among MSM with residence outside Vancouver and not known to have an HIV-positive partner.

CONCLUSIONS

These findings highlight potential missed opportunities for earlier detection of HIV and prevention of secondary transmission among newly diagnosed MSM and IDU, and provide evidence to inform recommendations for HIV test frequency and testing strategies for these populations in BC.

Factors associated with self-reported repeat HIV testing after a negative result in Durban, South Africa

Background

Routine screening for HIV infection leads to early detection and treatment. We examined patient characteristics associated with repeated screening in a high prevalence country.

Methods

We analyzed data from a cohort of 5,229 adults presenting for rapid HIV testing in the outpatient departments of 2 South African hospitals from November 2006 to August 2010. Patients were eligible if they were ≥18 years, reported no previous diagnosis with HIV infection, and not pregnant. Before testing, participants completed a questionnaire including gender, age, HIV testing history, health status, and knowledge about HIV and acquaintances with HIV. Enrollment HIV test results and CD4 counts were abstracted from the medical record. We present prevalence of HIV infection and median CD4 counts by HIV testing history (first-time vs. repeat). We estimated adjusted relative risks (ARR’s) for repeat testing by demographics, health status, and knowledge of HIV and others with HIV in a generalized linear model.

Results

Of 4,877 participants with HIV test results available, 26% (N = 1258) were repeat testers. Repeat testers were less likely than first-time testers to be HIV-infected (34% vs. 54%, p<0.001). Median CD4 count was higher among repeat than first-time testers (201/uL vs. 147/uL, p<0.001). Among those HIV negative at enrollment (N = 2,499), repeat testing was more common among those with family or friends living with HIV (ARR 1.50, 95% CI: 1.33–1.68), women (ARR: 1.24, 95% CI: 1.11–1.40), and those self-reporting very good health (ARR: 1.28, 95% CI: 1.12–1.45).

Conclusions

In this high prevalence setting, repeat testing was common among those undergoing HIV screening, and was associated with female sex, lower prevalence of HIV infection, and higher CD4 counts at diagnosis.

Tuberculosis in HIV-negative and HIV-infected patients in a low-incidence country: clinical characteristics and treatment outcomes

Background

In Switzerland and other developed countries, the number of tuberculosis (TB) cases has been decreasing for decades, but HIV-infected patients and migrants remain risk groups. The aim of this study was to compare characteristics of TB in HIV-negative and HIV-infected patients diagnosed in Switzerland, and between coinfected patients enrolled and not enrolled in the national Swiss HIV Cohort Study (SHCS).

Methods and Findings

All patients diagnosed with culture-confirmed TB in the SHCS and a random sample of culture-confirmed cases reported to the national TB registry 2000–2008 were included. Outcomes were assessed in HIV-infected patients and considered successful in case of cure or treatment completion. Ninety-three SHCS patients and 288 patients selected randomly from 4221 registered patients were analyzed. The registry sample included 10 (3.5%) coinfected patients not enrolled in the SHCS: the estimated number of HIV-infected patients not enrolled in the SHCS but reported to the registry 2000–2008 was 146 (95% CI 122–173). Coinfected patients were more likely to be from sub-Saharan Africa (51.5% versus 15.8%, P<0.0001) and to present disseminated disease (23.9% vs. 3.4%, P<0.0001) than HIV-negative patients. Coinfected patients not enrolled in the SHCS were asylum seekers or migrant workers, with lower CD4 cell counts at TB diagnosis (median CD4 count 79 cells/µL compared to 149 cells/µL among SHCS patients, P = 0.07). There were 6 patients (60.0%) with successful outcomes compared to 82 (88.2%) patients in the SHCS (P = 0.023).

Conclusions

The clinical presentation of coinfected patients differed from HIV-negative TB patients. The number of HIV-infected patients diagnosed with TB outside the SHCS is similar to the number diagnosed within the cohort but outcomes are poorer in patients not followed up in the national cohort. Special efforts are required to address the needs of this vulnerable population.

[Proposal of HIV, HBV and HCV targeted screening: short period feasibility study in a free-access outpatient medical structure]

OBJECTIVES

In France, patients coming from sub-Saharan Africa, French Indies and French Guiana are frequently missed HIV, HBV and HCV diagnosis, despite high prevalence of these infections.

METHODS

Targeted proposal of HIV, HBV and HCV screening, using sensitive enzyme immunoassays, to any adult patient originating of the above mentioned areas, with/without medical insurance, consulting for a medical issue in outpatients' department. Monocentric prospective study in a hospital in Paris during 28 consecutive days in 2010.

RESULTS

Among the 272 eligible patients, 166 were tested (patients' acceptance: 61%). 180/272 (66%) alleged being tested previously for HIV, women (66/87, 76%) more frequently than men (114/185, 62%), P=0.02. Patients' acceptance seemed higher in patients mentioning no previous test than in patients reporting previous test. Among the patients who refused being tested, reporting a previous negative HIV test, more than a quarter has been tested more than 1 year ago. Among the 166 tested patients, 120 (72%) came back to get their results, men (89/113, 79%) more frequently than women (31/53, 58.5%), P=0.009; recently metropolitan patients more frequently than longer metropolitan patients, P=0.01; patients without any job more frequently than patients with a job, P=0.01. Three (1.8%) HIV tests returned positive; HBsAg was positive in 13 (7.8%) patients; 54 patients (32.7%) had a negative hepatitis B screening (anti-HBcAb+HBsAg+anti-HBsAb), attesting to sensitivity to this infection, only 18 patients (10.9%) showed isolated anti-HBsAb at protective levels. Eighty-one patients (49.1%) exhibited anti-HBcAb, confirming the high prevalence of HBV infection in the areas the patients came from. Six patients (3.6%) had anti-HCVAb. There was no co-infection.

CONCLUSION

Targeted HIV, HBV and HCV screening to patients coming from high prevalence areas in outpatients' department appears a very cost-effective strategy.

Opportunities and challenges for cost-efficient implementation of new point-of-care diagnostics for HIV and tuberculosis

Stakeholders agree that supporting high-quality diagnostics is essential if we are to continue to make strides in the fight against human immunodeficiency virus (HIV) and tuberculosis. Despite the need to strengthen existing laboratory infrastructure, which includes expanding and developing new laboratories, there are clear diagnostic needs where conventional laboratory support is insufficient. Regarding HIV, rapid point-of-care (POC) testing for initial HIV diagnosis has been successful, but several needs remain. For tuberculosis, several new diagnostic tests have recently been endorsed by the World Health Organization, but a POC test remains elusive. Human immunodeficiency virus and tuberculosis are coendemic in many high prevalence locations, making parallel diagnosis of these conditions an important consideration. Despite its clear advantages, POC testing has important limitations, and laboratory-based testing will continue to be an important component of future diagnostic networks. Ideally, a strategic deployment plan should be used to define where and how POC technologies can be most efficiently and cost effectively integrated into diagnostic algorithms and existing test networks prior to widespread scale-up. In this fashion, the global community can best harness the tremendous capacity of novel diagnostics in fighting these 2 scourges.

First presentation for care of HIV-infected patients with low CD4 cell count in Lyon, France: risk factors and consequences for survival

To identify the risk factors associated with presentation for care with CD4 cell count ≤ 200 cells/mm(3) and death in HIV-infected patients in Lyon, France. Data were analyzed on participants from mid-1992 to December 2006 in the Lyon section of the French Hospital Database on HIV Infection. Patients were stratified into two categories according to CD4 cell count at first presentation for care in University of Lyon hospitals: Group 1 (Gr1) patients with CD4 ≤ 200 cells/mm(3) and Group 2 (Gr2) patients with CD4 >200 cells/mm(3). Multivariate logistic regression assessed the risk factors associated with first presentation for care with CD4 ≤ 200 cells/mm(3). Survival was analyzed according to the Cox regression model. Among 3569 eligible patients (838 females and 2731 males, mean age: 36.3 ± 10.3 years), 1139 (31.9%) were categorized as Gr1. The factors associated with first presentation for care with CD4 ≤ 200 cells/mm(3) were: older age, male gender, route of HIV transmission, migrant populations, geographical areas other than Rhône-Alpes, and access to care in 1992-1997. Overall mortality was higher in Gr1 than in Gr2 (24.4% [278/1139] vs. 4.1% [101/2430]; p<0.001). The risk of death was 5.81 [4.61-7.32] in Gr1 compared to Gr2. In addition to CD4 cell count, age and enrollment periods for care were factors independently related to death. Despite public health efforts in Lyon, one-third of HIV-infected patients reach the health care system with CD4 cell count ≤ 200 cells/mm(3), which was linked with higher mortality.

Late presenters, repeated testing, and missed opportunities in a Danish nationwide HIV cohort

BACKGROUND

We aimed to estimate the incidence and predictors of late presentation among human immunodeficiency virus (HIV)-infected individuals in Denmark.

METHODS

Incidence rates (IR) of presentation with advanced HIV (CD4 < 200 cells/μl and/or acquired immune deficiency syndrome (AIDS)) and late presentation (CD4 < 350 cells/μl and/or AIDS) were calculated per 100,000 population aged 16-60 y. Mortality rate ratios (MRR) were estimated using Poisson regression analysis.

RESULTS

Three thousand and twenty-seven individuals were diagnosed with HIV in 1995-2009; 34.7% presented with advanced HIV and 51.2% were late presenters. The IR of HIV was stable (6.2/100,000 population), but IR of presentation with advanced HIV declined during the study period from 2.2 (95% confidence interval (CI) 1.8-2.8) to 1.1 (95% CI 0.8-1.5). Age >50 y, heterosexuals of non-Danish origin, 'other' route of transmission, and diagnosis before 2002 were associated with an increased risk of presenting with advanced HIV, whereas a negative HIV test prior to diagnosis was associated with a significantly reduced risk. A total of 414 individuals (40.0%) had attended a hospital 1-3 y before presenting with advanced HIV. After 2002 the proportion of men who have sex with men with a negative HIV test prior to diagnosis increased (incidence rate ratio (IRR) 1.3, 95% CI 1.1-1.6), coinciding with a reduction in IR of presentation with advanced HIV. Mortality rates were increased the first 2 y following presentation with advanced HIV (MRR 5.9, 95% CI 3.6-9.4 and MRR 2.5, 95% CI 1.4-4.1, respectively).

CONCLUSION

In a setting with a low HIV prevalence, the rate of presentation with advanced HIV can potentially be reduced by repeated HIV testing of individuals with a continuous high risk of transmission and by adhering to guidelines for targeted HIV testing.